The proposed Hypersexual Disorder diagnosis now being considered by the APA for inclusion in the forthcoming DSM-5 has generated a great deal of heat in the therapeutic community. And frankly, there should always be significant dialog before any form of inherently healthy human behavior (eating, sleeping, sex, etc.) is clinically designated as pathological. After all, the power to “label” must always be carefully wielded to avoid turning social, religious, or moral judgments into clinical diagnoses (as occurred with homosexuality in the DSM-I and DSM-II). That said, equal care must be taken to not avoid researching and creating diagnostic criteria for such behaviors when they go awry. To that end, Dr. Marty Kafka of Harvard proposed a definition for Hypersexual Disorder to the DSM’s Workgroup on Sexual and Gender Identity Disorders, and a UCLA-led group of researchers embarked on a major study of the proposed criteria’s viability—the results of which are published in full in the October 2012 issue of The Journal of Sexual Medicine.[i]

Over a period of at least 6 months, recurrent intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior

repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability)

repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events

repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior

repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others

There is no clinically significant distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior.

These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring general medical condition or to Manic Episodes.

In a Controlled Environment
In Remission (No Distress, Impairment, or Recurring Behavior for Five Years in an Uncontrolled Environment)

The UCLA-led Study

Dr. Rory Reid, a research psychologist and assistant professor of psychiatry at the Semel Institute of Neuroscience and Human Behavior at UCLA, recently led a team of psychiatrists, psychologists, social workers, and marriage and family therapists in a study of 207 patients at several mental health clinics around the country. The research team was specifically chosen to include a diversity of backgrounds and levels of experience in working with sexual disorders (to test the reliability of Dr. Kafka’s proposed diagnostic criteria across the full spectrum of treatment options). The primary research site for this study was the Sexual Recovery Institute: Los Angeles, which I founded in 1995. Reid and his colleagues conducted psychological testing and interviews with 207 patients in total, all of whom had sought treatment for out-of-control sexual behavior, a substance abuse disorder, or another psychiatric condition such as depression or anxiety. Approximately 150 of the patients entered treatment because they were troubled by their sexual behaviors, with the remainder pursuing treatment for substance abuse or other, non-related psychiatric disorders.

The aim of the UCLA study was to learn if people who sought help for hypersexual behavior (sex addiction) would be accurately identified by the criteria and, at the same time, to see if people with other primary issues would (or would not) be falsely diagnosed as suffering from Hypersexual Disorder. As it turns out, Kafka’s proposed definition—drawn from decades of tier one, peer reviewed hypersexuality research—is well thought out. The researchers found that the proposed criteria accurately identified 88 percent of self-reported hypersexual (sexually addicted) patients as having the disorder. More importantly, the criteria accurately identified negative results (participants who did not seek treatment for hypersexual behavior) 93 percent of the time. For example, many of the people seeking treatment for substance abuse reported engaging in problematic sexual behavior, but only when drunk or high. The criteria identified only one of these individuals as hypersexual. For the rest, their primary disorder was recognized as being substance abuse. According to Reid, the ability of the criteria to accurately identify (and to not misidentify) patients as suffering from Hypersexual Disorder is actually quite high in comparison to other psychiatric diagnoses.[iii] Thus, the proposed definition appears to be reliable in terms of helping a broad array of mental health professionals accurately identify this affliction.

Other significant findings were that hypersexual behavior, like other addictions, tends to escalate (more time spent, or more sexually intense/arousing behaviors) and to cause a wide variety of negative life consequences. One other interesting finding was that 54 percent of hypersexual patients felt their sexual behavior began to be problematic before the age of 18, with another 30 percent reporting the behavior became problematic from 18 to 25. Thus we see that for most people Hypersexual Disorder emerges during adolescence or early adulthood. This finding may well impact early intervention and prevention strategies down the line.

The DSM-5

Documented evidence, including the UCLA-led study discussed above, increasingly points toward Hypersexual Disorder as a legitimate, serious, and not uncommon clinical condition associated with the related concerns of disease transmission, family and relationship dysfunction, mood disorders, anxiety, job loss, sexual dysfunction, and even suicide. Therefore it makes sense that a diagnosis should be imminent and forthcoming—even more so given recent findings. Nevertheless, it remains uncertain if the DSM-5 (to be released in early 2013) will include Hypersexual Disorder as a distinct diagnostic category. In fact, as of this writing the Hypersexual Disorder page on the APA website reads, in part, “This condition is being recommended for further study in Section III, which is the section of the DSM-5 text in which conditions that require further research will be included.”[iv] So at this time inclusion in Section III as a potential diagnosis for further research seems probable. And while this action feels a bit like “too little, too late” to offer guidance to treatment providers whose clients are seeking help now, it is nevertheless meaningful, as being a documented “potential diagnosis” brings with it a likely increase in much needed research funding and clinical focus.

The Future

After 20-plus years treating individuals who have self-reported compulsive and problematic sexual fantasies and behaviors, I can assure you the time has come—in fact, is past—for the DSM to recognize hypersexuality (sexual addiction) as a legitimate disorder. Furthermore, adding Hypersexual Disorder to the DSM-5 would go a long way toward removing the same kinds of moral stigma previously applied to alcoholics, drug addicts, and compulsive gamblers before those concerns were fully recognized as treatable addictions and legitimate disorders. Let us not forget that prior to proper diagnosis and treatment planning, alcoholics were simply bums, overeaters were fat and lazy, and compulsive gamblers were too sociopathic to not gamble away the family rent. With a Hypersexual Disorder diagnosis we would finally have a useful retort to those emotionally and psychologically damaging terms such as nympho, slut, and pervert, replacing them with a legitimate, informed diagnostic category from which useful treatment planning and further outcome studies could then be drawn.